American Academy of Emergency Medicine

Fact of the Day - March 2013

Brought to you by the AAEM Resident & Student Association (AAEM/RSA)

March 31, 2013

A systematic review advocates that emergency physicians should avoid meperidine and consider prescribing oxycodone to elderly patients when narcotics are indicated for pain control.

Ann Emerg Med. 2012;59

March 30, 2013

Because of an increasing incidence of pertussis cases attributed to waning immunity, the CDC in 2005 recommended Tdap for patients aged 11–64 years if they had not previously received Tdap. Adults 65 years or older receive Td.

MMWR Weekly, 1/27/12

March 29, 2013

Extended Focused Assessment with Sonography forTrauma (E-FAST) In addition to the 4-quadrant views of the FAST, includes views of both hemithoraces at the levels of the diaphragm-abdominal interface and over bilateral anterior chest walls.

EBMedicine.net, 2011

March 28, 2013

A review analysis of 540 records of children with cervical spine injury and random mechanism of injury identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to29%) specific for cervical spine injury.

Ann Emerg Med. 2011;58:145-155

March 27, 2013

In a prospective study, researchers demonstrated that Emergency department cardioversion of atrial fibrillation of short duration in stable, otherwise healthy patients is a safe and effective practice. Electrical cardioversion is more effective and takes less time than pharmacological conversion, and, with the addition of procedural sedation, is well tolerated by patients.

Emerg Med J 2012 Mar; 29:188

March 26, 2013

Differential diagnosis of alcohol-related seizures:

  • Withdrawal (alcohol or drugs)
  • Exacerbation of an underlying seizure disorder
  • Acute drug intoxication (eg, amphetamines, anticholinergics, cocaine, isoniazid, organophosphates, tricyclics, salicylates)
  • Metabolic disorders
  • Infections (CNS or systemic)
  • Trauma (acute or remote)
  • Stroke

Emerg Med Clin N Am 29 (2011) 117–124

March 25, 2013

The classic triad of CST is headache, papilledema, and high CSF opening pressure. MRI with magnetic resonance venography is considered the gold standard for diagnosis.

Am J EM, Vol. 25, pg. 218

March 24, 2013

After hemodynamic stabilization, upper endoscopy is the most accurate intervention in UGIB patients that allows for the diagnosis of the bleeding site with achievement of hemostasis in more than 90% of cases. Early esophagoduodenoscopy (EGD), performed within 12 to 24 hours of bleeding, reduces the risk of re-bleeding and hospital length of stay for patients with UGIB.

Emerg Med Clin N Am 29 (2011) 239–252

March 23, 2013

Ultrasonographically guided needle aspiration is insufficient therapy for skin abscesses. The presence of CA-MRSA decreases the success of both incision and drainage and ultrasonographically guided needle aspiration.

Ann Emerg Med. 2011;57:483-491

March 22, 2013

Intranasal naloxone is statistically as effective as IV naloxone at reversing the effects of opioid overdose. The IV and IN groups had similar average increases in RR and GCS. Thus, IN naloxone is a viable alternative to IV naloxone while posing less risk of needle stick injury.

American Journal of Emergency Medicine (2010) 28, 296–303

March 21, 2013

A nasal cannula set at 15 L/minute is the most readily available and effective means of providing apneic oxygenation during ED tracheal intubation. Although non-rebreather masks can provide high FiO2 levels to spontaneously breathing patients, they provide minimal oxygen to apneic patients (presumably because of the two exhalation valves venting the fresh gas flow).

Ann Emerg Med 2011 Nov 1

March 20, 2013

The most recent guidelines from the AHA for cardiac arrest patients with ROSC recommend titrating supplemental oxygen therapy to maintain an SpO2 greater than 94% and a PaO2 around 100 mm Hg. For intubated patients, positive end expiratory pressure (PEEP) can be titrated to maintain target oxygen saturation levels while minimizing exposure to high levels of inspired oxygen.

Emerg Med Clin N Am 30 (2012) 123–140

March 19, 2013

The role of bedside ultrasound in diagnosing pediatric appendicitis is not yet clearly defined. In a study of 132 patients (36% pediatric) the sensitivity and specificity of bedside ultrasound were found to be 65% and 90%, respectively. Diagnosis of appendicitis was based on finding a non-peristalsing tubular structure in the right lower quadrant that lacked compressibility and measured greater than 6 mm in diameter.

Ebmedicine.net, March 2012

March 18, 2013

Both azithromycin, 1 g orally as a single dose and doxycycline, 100 mg orally twice a day for 7 days are equally effective in treating chlamydia. Azithromycin is safe in pregnancy, whereas doxycycline is contraindicated. Single-dose therapy is inadequateto treat chlamydial infection of the upper female genital tract (eg, PID).

Emerg Med Clin N Am 29 (2011) 587–603

March 17, 2013

Further prospective, randomized, controlled studies comparing ketamine and ketamine/propofol need to be performed before one can conclude the combination regimen is faster than and as safe as ketamine alone.

EBMedicine.net, January 2011

March 16, 2013

It is important to remember that in toxic alcohol neither ethanol nor fomepizole will remove the toxic metabolites. Definitive treatment for acidotic patients and those with elevated methanol or ethylene glycol blood levels is hemodialysis.

American Journal of Emergency Medicine (2012) 30, 231–235

March 15, 2013

Widely accepted regimen for providing adequate sedation and analgesia in the majority of patients who require procedural sedation in the ED is an initial dose of 0.5 to 2.0 mg/kg of ketamine, followed by incremental doses of 0.5 to 1.0 mg/kg intravenously (IV) or 4.0 to 5.0 mg/kg intramuscularly (IM), followed by additional 2 to 4 mg/kg IM incremental dosing as needed.

EBMedicine.net, January 2011

March 14, 2013

Criteria to withhold or terminate care in Prehospital Trauma Resuscitation are: (1) blunt trauma with apnea, pulselessness, and no organized electrocardiogram activity; (2) penetrating trauma with the preceding clinical presentation and no other signs of life; (3) 15 minutes of cardiopulmonary resuscitation without return of spontaneous circulation; or (4) EMS-witnessed TCPA followed by 15 minutes of unsuccessful resuscitation en route to the ED.

J Trauma 2011 Oct; 71:997

March 13, 2013

There is no single specific test for the diagnosis of mesenteric ischemia. Most commonly, an anion gap acidosis, leukocytosis, and hemoconcentration are found with mesenteric ischemia. Increased lactate is independently associated with higher mortality.

Emerg Med Clin N Am 29 (2011)

March 12, 2013

A meta-analysis of 1140 patients with testicular torsion in 22 series demonstrated a greater than 90% salvage rate with surgery within 6 hours of pain onset. An accompanying meta-analysis of 535 patients in 8 series showed that the risk of subsequent testicular atrophy increased despite surgical detorsion beyond the 6-hour window.

Emerg Med Clin N Am 29 (2011) 469–484

March 11, 2013

The results of the Cochrane review indicate that either zolmitriptan or sumatriptan offer significant therapeutic benefit for patients with acute cluster headache. The best therapeutic outcomes were achieved with either intranasal zolmitriptan or subcutaneous sumatriptan administration compared with oral dosing or placebo.

Ann Emerg Med. 2011;58: 284-285

March 10, 2013

Severity of illness scores such as the CURB- 65 criteria or prognostic models such as the pneumonia severity index (PSI) can be used to identify patients with CAP who may be candidates for outpatient treatment. (A-I Evidence.)

EBMedicine.net, January 2012

March 09, 2013

Treatment with fomepizole or ethanol will inhibit the action of ADH and thus stop the conversion of the parent compounds, methanol and ethylene glycol, to their respective toxic metabolites.

EBMedicine.net, 2010, Volume 12, Number 11

March 08, 2013

The AHA states that there is insufficient evidence to advocate for the routine use of fibrinolytic agents during cardiac arrest but that their use should be considered on a case-by-case basis; they receive a level IIb recommendation for cardiac arrest secondary to pulmonary embolism.

Emerg Med Clin N Am 30 (2012) 65–75

March 07, 2013

In women, E. coli causes 75 to 95% of episodes of uncomplicated cystitis and pyelonephritis; the remaining cases are caused by other Enterobacteriaceae, such as Klebsiella pneumoniae, and gram-positive bacteria such as Staphylococcus saprophyticus, Enterococcus faecalis, and Streptococcus agalactiae (group B streptococcus).

N Engl J Med 2012;366:1028-1037

March 06, 2013

In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

Ann Emerg Med. 2011;58:200-204

March 05, 2013

The use of propofol for an orthopaedic procedure requiring sedation in the emergency department expedites patient management and saves time in comparison with the use of midazolam/ketamine.

J Bone Joint Surg Am 2011 Dec 21; 93:2255

March 04, 2013

Toddler’s fracture, as classically defined by Dunbar in 1964, is an isolated, subtle, undisplaced, spiral fracture of the distal tibial diaphysis in a toddler (9 months to 3 years old).Toddler’s fracture does not appear on the initial x-rays in a significant number of cases.

Emedhome.com, March 2011

March 03, 2013

Treatment Of Hyperkalemia In Children:

  • Sodium bicarbonate 1-2 mEq/kg IV over 10 minutes
  • Calcium gluconate 50-100 mg/kg (maximum dose 1 g) IV over 10 minutes
  • 2 mL/kg IV bolus of D25 plus 0.1 unit/kg IV regular insulin
  • Sodium polystyrene sulfonate -1 g/kg orally or rectally

Pediatric Emergency Medicine Practice, April 2011 , ebmedicine.net

March 02, 2013

The most common presenting sign of an arteriovenous malformation is intracerebral hemorrhage. Hemorrhage of AVMs accounts for 2% of strokes. Other presenting signs of AVMs include seizures, mass effect (from compression/swelling, putting pressure on nearby structures), and ischemic steal (from preferential low-resistance blood flow through the AVM, resulting in the hypoperfusion of other structures).

NEJM, Vol. 356, pg. 2704

March 01, 2013

At present, the known optimum single intravenous dose of opioid analgesics in treating acute pain in the ED does not exist. The best available evidence advocates for titration regardless of the choice of dosing (weight-based or fixed) until pain is relieved or side effects become intolerable.

Emedhome.com, March 2012